Revision to legislation in the US State of New Jersey will prohibit health care institutions from discharging prescription medications into sewer or septic systems.
How that will happen is pretty straightforward – don’t discharge unwanted medicines into a sink or drain. But what of the patients themselves, and for that matter any of the hospital staff who are taking any medication, from a couple of aspirin, to anti-hypertensives or diabetes medications, perhaps even oral contraceptives?
Urinary excretion is the elephant in the room. It accounts for the huge majority of wastewater pharmaceuticals – assuming no inappropriate discharges of waste pharmaceuticals. But that latter scenario must now be unlikely. The discharge of narcotic analgesics and anaesthetic agents into a sink, to put them immediately out of use – from the anaesthetic room and operating theatre or in the intensive care unit, is now almost completely stopped. It was, at the time, probably the best option but with medicines disposal kits that are designed to receive and put these liquid medications safely beyond use disposal to sink is no longer needed. Indeed, this was central to teaching by Blenkharn Environmental some 15+ years ago and we take some considerable pride at being at the forefront of this change in practice, working with the Royal College [then Faculty] of Anaesthetists.
But what about those bulk wastewater discharges. We give medicines to patients. Those medicines are excreted [mainly] in urine, largely unchanged but in some cases with several complex metabolites. Urine goes directly, or via a catheter bag or bedpan/bottle, to teh swere and it should be no surprise that wastewaters will contain a vast diversity of pharmaceutical residues.
It would be interesting to look more closely at the presence of pharmaceuticals also in wastewater from the staff toilets. That will surely be less, and less varied, that that from patient excretion, but should equate more generally to the content in discharges from the community.
It is entirely correct that New Jersey should seek to formalise the prohibition of deliberate discharge of pharmaceutical wastes to sewer. However, that elephant cannot be ignored, when regulators puff and blow about the occasional tablet or capsule, or trace of liquid residue in an empty syringe or length of tubing. And of course, if those de minimis residues are of concern then so too is all that blood, presently overlooked as an additional source of pharmaceuticals. If a trace does really make a difference, then every trace makes that difference.
Targeted wastewater treatments to remove pharmaceuticals from hospital wastewater outflows is going to be a useful, and perhaps soon, an essential and mandatory process. It will carry a substantial additional cost.
This is not a solution for other wastewater discharges, from domestic premises. Here, only improved community wastewater treatments will make any difference. Reliance on largely Victorian wastewater treatment systems is simply no use. Though some developmental research is taking place, the water companies are supported by the Environment Agency to stop us polluting wastewater, without any attempt to deal effectively with pollutants that pass through their systems and out into our rivers.
And at the same time, other sections of the Environment Agency get anxious about trace residues resulting from occasional segregation errors, imposing ever more ludicrous guidelines for classification of what does, and what does not, contain drug residues. And every time they get it wrong, basing their ideas on the shaky foundations of inadequate knowledge and understanding, while failing to consider the available evidence and some simple realities of drug administration and excretion that we reiterate above!
How can we move forward? It is important to consider all discharges and not only those which can be easily targeted, certainly addressing the bigger issues and not fussing disproportionately about relatively trivial issues at teh expense of that elephant. More research is required, into the fate of excreted pharmaceuticals in wastewater discharges, and later as they pass into teh environment from sewage treatment facilities. Regulation should be predicated on significant, attainable and meaningful targets that have their foundation in sound science. That science must be interpreted with care, with transparency and, almost always, after discussion with a range of relevant experts to ensure that the conclusions drawn are meaningful and not based on the whim of an individual. We generally call that a public consultation; that must be transparent, and those responsible for its undertaking must prove their neutrality and demonstrate clearly that the conclusions represent fully consensus opinion. Where evidence is not available to support any decision, then it is appropriate to consider some intervention but to revisit that decision when better and more meaningful data becomes available.
In the meantime, the water companies and Water UK must step up to the plate and accept that demanding fewer discharges to help reduce their own efforts in wastewater treatments simply will not work. What is the alternative? Perhaps they would prefer that we piss up against the wall, in fact anywhere but into the sewer!